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R 5923 I APPLICATION FOR CITY OF CUPERTINo NUMBER PERMIT R- 5923 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS Pd Z J ( �Q i� / (./ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �/� YES E] If yes—I understand that a Class A / NAME / -l A.! °I / ( Q 2 /-� �-1 roof assembly Is required. l,� !� ^T e' NO ❑ InNal I.C.B.O.# ADDRESS_�x2 3 / (J `✓ Q`h / ( J lwi I EXISTING ROOF COVERING PHONE G — / 7 / NUMBER OF EXISTING COVERINGS CONTRACTORS NAME ) P J I/ ,/ /'1 t/' TO BE REMOVED TO BE RETAINED ADDRESS TYPE OF ROOF COV CITY&ZIP 410'1 Z 4QkneC /-e,7 01� PAI n 7 - 2 - EXISTINGp��I� PHONE YO-O —7 ' 3��P 7 UN EUT-DaOF ❑ xv, CENSE NUMBER CI I f lrt ASPHALTISHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am Ilcensed under provisions of Chapter g(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and enact. _C_ WOOD SHINGLES. ❑ License Class Lic.Number / 9 �/ DateG � Contractor eJ OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the following reason. (See.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,attar.improve.demolish,or repair any structure,prior to Its Issuance,also requires theBUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ❑ of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑I,as owner of the property,or my employee$with wages as their sofa compensation,will do WOOD SHAKES ' the work,and the structure Is not intended or offered for sale(Sac.7044,Business and Profes. stone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not intended or offered for sale.It,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. C]I am exempt under Sec. ,B 6 P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ��OP ❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Buildingas provided for by Section 3700 of the Labor Code,for the performance of the work for which this G� Q 12-0' s� permit is issued. 2 ` `9 (2-1 2-7 Q .'D Seismic .01 have and will the performance Workers f the work for Insurance,as permit by Section Worker's's the Lector Code,for the penormenee of the work for which this permit la lasuetl.My Worker's v / Z� Compensation�Insurrarr ran ance catl7Q Poll/cy number are: Total Carrier s / " Policy No. P PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C-0 (This section need not be completed It the permit is for one hundred dollars($100)or lose.) �—� I certify that in the performance of the work for which this permit is Issued,I shell not employ any person In any manner so as to become subject to the Werkera'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being forms. p r installed. If a roof is installed without first obtaining an Date—C'�� / Applicant T e y r j,,, J 0 ( inspection,I agree to remove all new materials for inspection. NOT me subject toE eOWorrkereCCompef,after ns tion prolvisionls at ttheiLate of borr Code,yolu mustushould forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shaNbe deemed revoked, Source regulations. I certify that I have read this application and stale that the above Information Is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings t0 be class&or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino agatrial liabilities, judgments, granting of this pemiexpenses which may In any way soros against said City?nconsequence SIGNATURE OF APPLICANT DATE PRE-INSPECTION•. PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATE INSP. - DATE TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY